Get Ready for a Lot of Biden Executive Orders on Health Care

In this column for the JAMA Health Forum, Larry Levitt explores what President-elect Biden might do to advance his health care vision both through legislation and through executive orders and waivers and demonstrations.

Potential Health Policy Administrative Actions Under President Biden

This brief outlines the potential health policy actions that President Biden could take using executive authority, based on campaign pledges, and actions that would reverse or modify regulations or guidance issued by the Trump Administration.

California Lawmakers to Newsom: Give All Immigrants Health Coverage

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SACRAMENTO — California Democratic lawmakers so far have failed to convince Gov. Gavin Newsom that the state can afford to spend an estimated $2.6 billion a year to expand its Medicaid program to all unauthorized immigrants.

Now, they’re trying a new strategy.

Rather than working independently, a fiercely liberal state senator from Los Angeles and a moderate Assembly member from the Central Valley are joining forces to pressure Newsom to make California the first state in the nation to cover every income-eligible resident regardless of immigration status. Unauthorized immigrants up to age 26 can already qualify for Medi-Cal, the state’s Medicaid program for low-income residents.

Emboldened by the win of Democratic President-elect Joe Biden and spurred by the urgency of the coronavirus pandemic, state Sen. María Elena Durazo (D-Los Angeles) and Assembly member Joaquin Arambula (D-Fresno) plan to introduce a two-bill package on Monday that would cover unauthorized senior immigrants first, and eventually the remainder of California’s undocumented immigrant population.

“It’s a national issue. Look at how all the national Democratic candidates raised their hands in front of the world to support covering undocumented immigrants in health insurance,” Durazo told California Healthline. “We want a clear commitment to finally do this, not just lip service.”

Newsom has long touted his goal of achieving universal health coverage in California and made campaign promises to work toward a single-payer health care system. But after nearly two years in office, Newsom’s ambitious health care agenda has been sidetracked by deadly wildfires and a widening homelessness crisis — as well as the COVID-19 pandemic — and he has not managed to dramatically expand coverage.

California currently covers about 200,000 unauthorized immigrant children and young adults, according to the state Department of Health Care Services. The state budgeted about $375 million to cover young adults ages 19 through 25 this fiscal year, but does not track spending for undocumented immigrant children, according to the state Department of Finance.

Opening the low-income health program to all eligible undocumented immigrants would expand coverage to at least 915,000 low-income residents and cost an additional $2.6 billion annually, according to a projection this year by the nonpartisan state Legislative Analyst’s Office. There are an estimated 1.5 million undocumented immigrant Californians who are uninsured, estimates show, but not all of them would qualify.

Public support for expanding coverage to unauthorized immigrants has risen over the past few years, according to the Public Policy Institute of California. But expending scarce taxpayer resources on such an effort is politically risky, said Doug Herman, a Los Angeles-based national Democratic strategist.

“Gavin’s got bigger priorities right now and he has been wounded, so he has to be very cautious about what he does,” Herman said. “Look at the French Laundry and [Employment Development Department] scandals. The homelessness crisis is raging and the prison outbreak happened on his watch. This doesn’t rise to that level.”

Newsom communications director Jesse Melgar said no one from his office was available for comment.

Since Newsom took office, Durazo and Arambula have authored separate bills to expand Medi-Cal to more undocumented immigrants. Durazo has gotten close after negotiating with Newsom — only for the first-term Democratic governor to back out, citing costs.

Such proposals have received widespread legislative support among Democratic lawmakers, who hold supermajority power in both houses of the state legislature.

A worsening economic outlook and long-term budget pressures could once again derail their efforts. Because the federal government prohibits states from using federal Medicaid dollars to cover undocumented immigrants — except for emergency services — California would have to pick up most of the price tag, which could top $3 billion annually to cover everyone, including children and adults, according to the Legislative Analyst’s Office.

Newsom will be forced to weigh an onslaught of budget demands while managing, and paying for, the ongoing COVID-19 emergency.

“That gives Newsom the ability to delay or oppose anything that doesn’t fit his agenda,” Herman said.

But some lawmakers, immigration rights activists and health care advocates argue the COVID pandemic has made their campaign more urgent as Latino and Black residents get sick and die at disproportionate rates.

Politicians cannot ignore that the pandemic has exposed a broken health care system that has left millions of taxpaying Californians without health coverage because their immigration status renders them ineligible, said Sarah Dar, director of health and public benefits for the California Immigrant Policy Center, which is already lobbying the governor to support the Medi-Cal expansion.

“Now we have a full picture of what this crisis is, and the blatant disparities faced by our essential workers, so there’s no excuse,” she said. “Immigrant communities and farmworkers in the food and agricultural sector, like meatpacking plants, have literally been hotbeds for the spread of disease.”

Dar acknowledged financial pressures ahead for the state, and said advocates will be pushing for ways to generate money to pay for the expansion, possibly including tax increases.

There could be some hope for a one-time cash infusion. Fiscal estimates show California could reap a $26 billion surplus next year, largely from personal income tax receipts from high-income earners who have not suffered devastating economic losses during the pandemic, according to state fiscal analysts. Durazo and Arambula are eyeing that revenue for the Medi-Cal expansion.

“He has routinely stated his vision, but we’d like Gov. Newsom to deliver on health care for all during his governorship,” Arambula said. “I’m not going to sit and wait.”

Durazo said she would introduce a bill Monday to expand Medi-Cal to unauthorized immigrant Californians age 65 and older. She put a similar bill on hold in 2019, in exchange for a commitment from Newsom to include the proposal in this year’s state budget.

Newsom included the proposal in the first version of his state budget in January, but then withdrew it, citing soaring unemployment, business closures and an economy decimated by the pandemic.

Durazo and other backers decided to craft a new approach: Alongside Durazo’s bill to cover older adults, Arambula plans to introduce companion legislation to cover all undocumented immigrant adults.

The lawmakers are using the two bills as a negotiating tactic. Arambula and advocates said they hope to win coverage for undocumented immigrants 65 and older next year, while developing a plan with Newsom to expand coverage to the entire population at some point during his governorship.

Durazo said both bills are equally important and are intentionally being used to pressure the governor into action next year.

“This is our way to finally have a real conversation about what it’ll take to get everyone covered, given we’ll have federal partners with the Biden-Harris administration,” said Orville Thomas, director of government affairs for the California Immigrant Policy Center.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Republican Convention, Day 4: Fireworks … and Shining a Light on Trump’s Claims

President Donald Trump accepted the Republican Party’s nomination for president in a 70-minute speech from the South Lawn of the White House on Thursday night.

Speaking to a friendly crowd that didn’t appear to be observing social distancing conventions, and with few participants wearing masks, he touched on a range of topics, including many related to the COVID pandemic and health care in general.

Throughout, the partisan crowd applauded and chanted “Four more years!” And, even as the nation’s COVID-19 death toll exceeded 180,000, Trump was upbeat. “In recent months, our nation and the entire planet has been struck by a new and powerful invisible enemy,” he said. “Like those brave Americans before us, we are meeting this challenge.”

At the end of the event, there were fireworks.

Our partners at PolitiFact did an in-depth fact check on Trump’s entire acceptance speech. Here are the highlights related to the administration’s COVID-19 response and other health policy issues:

“We developed, from scratch, the largest and most advanced testing system in the world.” 

This is partially right, but it needs context.

It’s accurate that the U.S. developed its COVID-19 testing system from scratch, because the government didn’t accept the World Health Organization’s testing recipe. But whether the system is the “largest” or “most advanced” is subject to debate.

The U.S. has tested more individuals than any other country. But experts told us a more meaningful metric would be the percentage of positive tests out of all tests, indicating that not only sick people were getting tested. Another useful metric would be the percentage of the population that has been tested. The U.S. is one of the most populous countries but has tested a lower percentage of its population than other countries.

The U.S. was also slower than other countries in rolling out tests and amping up testing capacity. Even now, many states are experiencing delays in reporting test results to positive individuals.

As for “the most advanced,” Trump may be referring to new testing investments and systems, like Abbott’s recently announced $5, 15-minute rapid antigen test, which the company says will be about the size of a credit card, needs no instrumentation and comes with a phone app through which people can view their results. But Trump’s comment makes it sound as if these testing systems are already in place when they haven’t been distributed to the public.

“The United States has among the lowest [COVID-19] case fatality rates of any major country in the world. The European Union’s case fatality rate is nearly three times higher than ours.”

The case fatality rate measures the known number of cases against the known number of deaths. The European Union has a rate that’s about 2½ times greater than the United States.

But the source of that data, Oxford University’s Our World in Data project, reports that “during an outbreak of a pandemic, the case fatality rate is a poor measure of the mortality risk of the disease.”

A better way to measure the threat of the virus, experts say, is to look at the number of deaths per 100,000 residents. Viewed that way, the U.S. has the 10th-highest death rate in the world.

“We will produce a vaccine before the end of the year, or maybe even sooner.”

It’s far from guaranteed that a coronavirus vaccine will be ready before the end of the year.

While researchers are making rapid strides, it’s not yet known precisely when the vaccine will be available to the public, which is what’s most important. Six vaccines are in the third phase of testing, which involves thousands of patients. Like earlier phases, this one looks at the safety of a vaccine but also examines its effectiveness and collects more data on side effects. Results of the third phase will be submitted to the Food and Drug Administration for approval.

The government website Operation Warp Speed seems less optimistic than Trump, announcing it “aims to deliver 300 million doses of a safe, effective vaccine for COVID-19 by January 2021.”

And federal health officials and other experts have generally predicted a vaccine will be available in early 2021. Federal committees are working on recommendations for vaccine distribution, including which groups should get it first. “From everything we’ve seen now — in the animal data, as well as the human data — we feel cautiously optimistic that we will have a vaccine by the end of this year and as we go into 2021,” said Dr. Anthony Fauci, the nation’s top infectious diseases expert. “I don’t think it’s dreaming.”

“Last month, I took on Big Pharma. You think that is easy? I signed orders that would massively lower the cost of your prescription drugs.”

Quite misleading. Trump signed four executive orders on July 24 aimed at lowering prescription drug prices. But those orders haven’t taken effect yet — the text of one hasn’t even been made publicly available — and experts told us that, if implemented, the measures would be unlikely to result in significant drug price reductions for the majority of Americans.

“We will always and very strongly protect patients with preexisting conditions, and that is a pledge from the entire Republican Party.”

Trump’s pledge is undermined by his efforts to overturn the Affordable Care Act, the only law that guarantees people with preexisting conditions both receive health coverage and do not have to pay more for it than others do. In 2017, Trump supported congressional efforts to repeal the ACA. The Trump administration is now backing GOP-led efforts to overturn the ACA through a court case. And Trump has also expanded short-term health plans that don’t have to comply with the ACA.

“Joe Biden recently raised his hand on the debate stage and promised he was going to give it away, your health care dollars to illegal immigrants, which is going to bring a massive number of immigrants into our country.”

This is misleading. During a June 2019 Democratic primary debate, candidates were asked: “Raise your hand if your government plan would provide coverage for undocumented immigrants.” All candidates on stage, including Biden, raised their hands. They were not asked if that coverage would be free or subsidized.

Biden supports extending health care access to all immigrants, regardless of immigration status. A task force recommended that he allow immigrants who are in the country illegally to buy health insurance, without federal subsidies.

“Joe Biden claims he has empathy for the vulnerable, yet the party he leads supports the extreme late-term abortion of defenseless babies right up to the moment of birth.”

This mischaracterizes the Democratic Party’s stance on abortion and Biden’s position.

Biden has said he would codify the Supreme Court’s ruling in Roe v. Wade and related precedents. This would generally limit abortions to the first 20 to 24 weeks of gestation. States are allowed under court rulings to ban abortion after the point at which a fetus can sustain life, usually considered to be between 24 and 28 weeks from the mother’s last menstrual period — and 43 states do. But the rulings require states to make exceptions “to preserve the life or health of the mother.” Late-term abortions are very rare, about 1%.

The Democratic Party platform holds that “every woman should have access to quality reproductive health care services, including safe and legal abortion — regardless of where she lives, how much money she makes, or how she is insured.” It does not address late-term abortion.

PolitiFact’s Daniel Funke, Jon Greenberg, Louis Jacobson, Noah Y. Kim, Bill McCarthy, Samantha Putterman, Amy Sherman, Miriam Valverde and KHN reporter Victoria Knight contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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They Cared for Some of New York’s Most Vulnerable Communities. Then 12 Died.

Dr. Reza Chowdhury didn’t charge copays when his patients were low on cash. He gave them his home phone number and answered their medical questions at all hours. Once, when Chowdhury’s daughter, Nikita Rahman, struck up a conversation with a New York taxi driver, it turned out that he was from Bangladesh and knew her dad: “Dr. Reza? He’s my doctor — he’s the best doctor!” she recalled.

An internal medicine physician with a practice in the Bronx, Chowdhury had studied medicine in his native Bangladesh before immigrating to the United States 30 years ago. He left his family back home while he settled in, and worked as a tutor, a waiter and a security guard as he trained to practice in the U.S.

When COVID-19 came to New York, Rahman pleaded with her father, who had had a kidney transplant and was therefore immunocompromised, to stay home. But he kept working until mid-March, when he developed symptoms. He died on April 9.

The U.S. relies on immigrant labor — from doctors to nurses to health aides — to keep its health system afloat. And now immigrant health workers are dying at high rates during the pandemic. Lost on the Frontline, a joint project by KHN and The Guardian, has found that nearly one-third of health care workers who were confirmed to have died of COVID-19 were born outside the U.S. However, immigrants account for just 14% of the U.S. population and 18% of its health care force.

Chowdhury, 58, belonged to a nonprofit network of health care providers in New York called SOMOS that has been devastated during the pandemic. Founded with the aim of providing “culturally competent care” to low-income New Yorkers, most of its 2,500 physicians and nurses are immigrants, like their patients. They come from Bangladesh, the Dominican Republic and Egypt, among other places. In the early months of the pandemic, SOMOS reported that 12 of its physicians and nurse practitioners had died of COVID-19.

“Our patients are the ones who wash dishes, prepare food, ride buses, drive taxis,” said Dr. Ramon Tallaj, SOMOS’ chairman and co-founder. “And we’re risking our lives for our patients.” Chowdhury practiced in a working-class section of the Bronx, a borough hit hard by the coronavirus.

Most of SOMOS’ practitioners are primary care providers — family doctors, pediatricians, nurse practitioners. “We’re neighborhood doctors,” Tallaj said. “We work with poor people in poor neighborhoods, and we speak the same languages as our patients — none of our doctors are on Park Avenue.”

He said that at the outset of the pandemic public attention and funding went to hospitals and emergency care, while he and his colleagues pooled resources to buy personal protective gear and set up neighborhood testing sites.

It turns out that this early exposure to patients, before they were sick enough to visit the ER,  might have made these workers more vulnerable: A recent study found that primary care providers “may have been more likely to see patients with early-stage, mild or asymptomatic — but still contagious — SARS-CoV-2 infection, while having little to no personal protective equipment.”

Family physician Dr. Ydelfonso Decoo, 70, was the quintessential neighborhood doctor. From his practice in New York City’s Washington Heights, he saw generations of patients walk through his doors. Patients and their families — many immigrants from the Dominican Republic, like him — stopped to say hello when they saw him in the street.

“He loved his community and he always took time to listen to them,” said Dorka Cáceres, his assistant of 20 years. Decoo saw patients through late March, when he developed symptoms.

Dr. Ashraf Metwally was a Brooklyn family physician originally from Egypt. Dahlia Ibrahim, a family friend, described him as a “staple” in the local Arab community. A cancer survivor who helped out in emergency rooms early in the pandemic, Metwally “helped people. That’s just who he was,” Ibrahim wrote.

“These providers were like firefighters,” said Liz Webb, SOMOS’ vice president for human resources. “They were going into their communities, communicating in their languages, and making sure [people] didn’t worry about their immigration status” when seeking out testing, she said.

To cope with the loss of their colleagues and uncertainty about the future, SOMOS doctors have organized a nightly prayer group on Zoom that draws dozens of participants. And they’ve begun to lend their services to new COVID hot spots: This summer, they sent health workers to Georgia and Florida to volunteer in clinics and hospitals.

Chowdhury’s family has spent the past few months learning what he meant to his patients. They were overwhelmed by the outpouring of grief and support from people around the world who had sought his care or advice at one point or another. When they held an online memorial, they struggled to find a platform that could accommodate everyone who wanted to pay their respects, Chowdhury’s daughter said.

“Zoom maxes you out at, like, 200 users, so we used another [service] that allowed 500, and even then we were at capacity,” she said.

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Many People of Color, Immigrants Among 1,080 US Health Workers Lost to COVID

More than 1,000 front-line health care workers reportedly have died of COVID-19, according to Lost on the Frontline, an ongoing investigation by The Guardian and KHN to track and memorialize every U.S. health care worker who dies from the coronavirus. Earlier this month, the organizations published a major interactive database. It is the most comprehensive accounting of U.S. health care workers’ deaths in the country.

The virus has taken a disproportionate toll on communities of color and immigrants — and health workers haven’t been spared.

Guardian and KHN reporters have published profiles of 177 of the 1,080 victims we have identified based on obituaries, news reports, social media posts and other sources. Of those 177, 62.1% were identified as Black, Latino, Asian/Pacific Islander or Native American, and 30.5% were born outside the United States. Both figures support findings that people of color and immigrants (regardless of race) are dying at higher rates than their white and U.S.-born counterparts.

These figures track with other research. According to a Harvard Medical School study published in The Lancet Public Health last month, health care workers of color were more likely to care for patients with suspected or confirmed COVID-19 and nearly twice as likely as their white counterparts to test positive for the coronavirus.

The U.S. health system also relies heavily on immigrant health workers, who account for almost 1 in 5 health workers. Immigrant health workers tend to work in the most vulnerable communities: A 2018 study found that high-poverty areas tend to have more foreign-trained doctors than do wealthier regions, for example.

Among those lost were Corrina and Cheryl Thinn, sisters who worked in a clinic in the Navajo Nation in northern Arizona. They shared an office, lived in the same home, helped raise each other’s children and died just weeks apart.

Dr. James “Charlie” Mahoney, a Brooklyn pulmonologist, was one of only a handful of Black students at his medical school in the 1970s. He was remembered as a “legend” at his hospital.

Dr. Reza Chowdhury, an internist in the Bronx, was a beloved figure in the city’s Bangladeshi community. He didn’t charge copays when his patients were low on cash and gave out his home phone number so they could call with medical questions.

And Milagros Abellera, remembered by colleagues as a “mother hen,” was one of the dozens of nurses from the Philippines who succumbed to the virus in the United States.

In addition to disparities based on race and origin, our researchers found that of the 177 workers profiled so far from the Lost on the Frontline database:

  • At least 57 (32%) were reported to have had inadequate personal protective equipment (PPE).
  • The median age was 57 and ages ranged from 20 to 80, with 21 people (12%) under 40.
  • Roughly 38% — 68 — were nurses, but the total also includes physicians, pharmacists, first responders and hospital technicians, among others

You can read their stories and those of other healthcare workers here. And if you know of a health care worker who died of COVID-19, please share their story with us.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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With DACA Ruling, Did Supreme Court Grant Trump New Powers To Reshape Health Care?

President Donald Trump came into office vowing to repeal and replace Obamacare. While he successfully neutralized the health care law’s requirement that everyone carry insurance, the law remains in effect.

When Fox News host Chris Wallace noted that Trump has yet to put forward a replacement plan, Trump told him to stay tuned.

“We’re signing a health care plan within two weeks, a full and complete health care plan that the Supreme Court decision on DACA gave me the right to do,” Trump said July 19 on “Fox News Sunday.”

“The Supreme Court gave the president of the United States powers that nobody thought the president had.”

Trump said he would “do things on immigration, on health care, on other things that we’ve never done before.”

We wanted to know if the Supreme Court really did that. So we ran the president’s words by a number of people who study constitutional and administrative law. We heard several reasons why the Supreme Court might not have said what Trump thinks it said.

The Likely Source

We asked the White House press office for the basis of Trump’s assertion and never heard back. Several law professors pointed to a National Review article by University of California-Berkeley law professor John Yoo, best known as authoring a legal justification that led to waterboarding enemy combatants during the George W. Bush administration.

In the article, Yoo argues that when the Supreme Court ruled against the administration’s rollback of Deferred Action for Childhood Arrivals, or DACA, the court made it more difficult for new presidents to unwind the policies of their predecessors.

How might this give Trump new power?

In theory, Trump could enact a policy, even one judged illegal by the courts, and the person who follows him into office would need to jump through a number of hoops to undo it.

Yoo wasn’t sure if Trump could use the argument to make sweeping changes in health care, saying it “depends on what the administration policy actually says.”

But as Yoo sees it, should Trump establish a new program, the ruling “requires his successor to follow a burdensome process, which could take a year or more, to repeal it.”

Many legal experts disagree with Yoo’s interpretation. Before we go there, we need to recap the court’s DACA decision.

Court Sends DHS Back to the Drawing Table

President Barack Obama created DACA on the grounds that every administration has to allocate limited prosecution resources. Obama argued that it was more important to deport violent criminals, drug dealers and thieves than people who had come into the country illegally when they were little. So long as they had committed no serious offenses and met other criteria, they could apply to avoid deportation.

Under Trump, the Department of Homeland Security moved to end DACA. Supporters of the program sued, saying that under the Administrative Procedure Act, that action was arbitrary. In its June 18 ruling, a 5-4 majority on the Supreme Court agreed.

The ruling describes how Homeland Security Secretary Kirstjen Nielsen got in a procedural bind when she inherited the decision of her predecessor (Acting Secretary Elaine Duke) to end the program. She erred, Chief Justice John Roberts wrote, because instead of making the case for ending DACA as her own decision, she came up with new reasons to justify the earlier move.

“Because Nielsen chose not to take new action, she was limited to elaborating on the agency’s original reasons,” Roberts wrote. “But her reasoning bears little relationship to that of her predecessor and consists primarily of impermissible ‘post hoc rationalization.’”

The court didn’t say Homeland Security couldn’t change the policy. It said the Administrative Procedure Act requires an agency to consider the key options it faces and explain why it chose the one it picked. With DACA, it said the change needed to show a fuller vetting of its choices.

No New Power Created

So while Trump technically lost that case, he is using the ruling (and Yoo’s theory) to voice confidence that he can do things no one thought possible.

Legal scholars give several reasons that might be off the mark. Broadly, they say the court’s ruling changed nothing.

“It’s a straightforward application of long-standing administrative law doctrine that dates back at least to President Ronald Reagan,” said Cary Coglianese, director of the Penn Program on Regulation and a professor of law at the University of Pennsylvania. “Agencies have to explain why they are doing something. They have to look at the plausible alternatives and give a reason for the one they selected.”

Justice Brett Kavanaugh also did not see a new take on an old law. In his dissenting opinion, he called the ruling on the Administrative Procedure Act “narrow.”

In a similar vein, the court left intact the specific power behind DACA of selective enforcement of the law.

“That’s an ordinary part of executive branch practice, and nothing in the Supreme Court’s DACA decision should be read to authorize anything beyond that simple practice,” said Yale University law professor Cristina Rodríguez.

The path to undoing this sort of executive action may not be as long as Yoo described. The court spelled out how Nielsen could have ended DACA without much delay, said Eric Freedman, professor of constitutional law at Hofstra University Law School.

“If she had considered other possible solutions, what she did would have been fine,” Freedman said. “She would have complied with the Administrative Procedure Act and no one would have enjoined her.”

There is also something unusual about DACA itself that makes it less of a model for other steps Trump might take.

The program was in place for quite a while before Trump tried to end it. As a result, about 700,000 people ultimately counted on it. The court said that reliance on the program should have factored into the decision to end it.

A new policy from Trump wouldn’t have time to accumulate that critical mass.

“Anything Trump does now will be enjoined tomorrow,” said Josh Blackman at the South Texas College of Law. “So there will be no reliance, and the next administration could do what it wanted.”

Blackman said the court’s ruling did create some murkiness around challenging the legality of an unwanted policy. But he said an agency could justify a change strictly for reasons of policy, not law.

Lastly, the DACA decision was about a policy not to enforce the law in certain circumstances. Robert Chesney at the University of Texas Law School said that focus also limits the scope of the ruling.

“If Trump wants to create new rules, the example does not fit in the first place,” Chesney said.

A “full and complete health care plan” and major immigration changes would likely require new government actions. Without new laws from Congress, that would be out of reach.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.